Healthcare Provider Details

I. General information

NPI: 1679519086
Provider Name (Legal Business Name): RICHARD WAYNE MARTIN LCSW, LMFT,LPC,CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 NORTH PELHAM ST. BOX 622
RHINELANDER WI
54501-0622
US

IV. Provider business mailing address

6460 LOGGING CAMP RD
RHINELANDER WI
54501-8102
US

V. Phone/Fax

Practice location:
  • Phone: 715-365-6696
  • Fax: 715-365-6768
Mailing address:
  • Phone: 715-282-8655
  • Fax: 715-365-6768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4249-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: